Just when I thought I had seen everything when it comes to deciding who gets health insurance and who does not, comes a report in Sunday's New York Times about how Tennessee administers its Medicaid program for "medically needy" residents. These are people who have very high medical bills, but would normally not qualify for Medicaid because their income is too high. If their medical debt is high enough that their income falls below a certain threshold after the medical debt is taken into account, they may be eligible for Medicaid. Qualifying for Medicaid may mean the difference between having access to needed health care and being unable to get treatment for a high-cost illness. Keep in mind that to qualify for the program, in addition to having high medical bills such that they are impoverished after the bills are paid, people must be elderly, blind, disabled, or be the caretaker of a child who qualifies for Medicaid. These traditional Medicaid populations are considered by society to be "the neediest among us," according to Justice Roberts' opinion on the Affordable Care Act's Medicaid expansion.

Apparently, Tennessee limits enrollment in this program to the first 2,500 eligible callers who get through on the phone to the Tennessee Department of Human Services starting at 6:00 p.m. on a particular day once every six months. So if you are one of "the neediest among us," and happen to be able to continually hit "re-dial" on your phone at that time, or can use multiple phone lines to call, you might get lucky enough to get health insurance. According to the executive director of the Tennessee Justice Center, this system leaves "huge numbers of desperately ill people . . . out in the cold." As lawmakers in many states (including Tennessee) debate about whether to expand Medicaid under the Affordable Care Act, they should consider whether or not the richest country in the world should require some of its most vulnerable residents to play the equivalent of a game of roulette in order to get access to health care.